What are the management guidelines for pancreatic disease?

Management of Pancreatic Disease (Acute Pancreatitis)

All patients with severe acute pancreatitis must be managed in a high dependency unit or intensive care unit with full monitoring and systems support, while mild cases can be managed on general wards with basic monitoring. 1, 2

Initial Assessment and Severity Stratification

Severity assessment must be performed immediately upon presentation using objective criteria to guide management decisions. 3

• Diagnosis should be confirmed within 48 hours of admission using serum lipase (preferred over amylase when available) 1
• Monitor hematocrit, blood urea nitrogen, creatinine, and liver function tests as severity indicators 3
• Apply Atlanta criteria for severity classification, but organ failure resolving within 48 hours should not classify the attack as severe 1
• Predict severity using clinical impression, obesity, APACHE II score in first 24 hours, C-reactive protein >150 mg/L, Glasgow score ≥3, or persisting organ failure after 48 hours 1
• CT severity index stratifies mortality risk: scores 0-3 (3% mortality), 4-6 (6% mortality), 7-10 (17% mortality) 3

Fluid Resuscitation

Initiate goal-directed fluid resuscitation immediately with lactated Ringer's solution (preferred over normal saline) to maintain urine output >0.5 mL/kg body weight. 2, 3, 4

• Administer fluids during the first 6-12 hours of presentation 5
• Monitor central venous pressure frequently to guide fluid replacement rate 3
• Exercise caution with fluid administration in patients >55 years or those with preexisting organ failure 5
• Avoid hydroxyethyl starch (HES) fluids 3
• Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate assesses tissue perfusion adequacy 2

Monitoring Requirements

Mild Acute Pancreatitis

• Basic monitoring: temperature, pulse, blood pressure, urine output 3
• Peripheral intravenous line and possibly nasogastric tube 3
• Indwelling urinary catheters rarely warranted 3

Severe Acute Pancreatitis

• Hourly monitoring of pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 2, 3
• Peripheral venous access, central venous line, urinary catheter, and nasogastric tube placement 3
• Regular arterial blood gas analysis (hypoxia and acidosis may be detected late clinically) 3
• Maintain oxygen saturation >95% with supplemental oxygen 3
• Strict asepsis for all invasive monitoring equipment 3

Pain Management

Pain control is a clinical priority requiring immediate attention with a multimodal approach. 2, 3

• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 2
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 2
• Consider epidural analgesia as alternative or adjunct to intravenous analgesia, particularly for moderate to severe pain 2, 4
• Avoid NSAIDs in patients with acute kidney injury 2, 3
• No evidence supports restrictions in pain medication otherwise 2

Nutritional Support

If nutritional support is required, use the enteral route over total parenteral nutrition to prevent gut failure and infectious complications. 1, 2, 3

Mild Acute Pancreatitis

• Begin oral feeding within 24 hours when nausea, vomiting, and abdominal pain are improving 3, 5
• Clear liquid diet is no longer recommended 4
• Routine nil per os status is unnecessary 3

Severe Acute Pancreatitis

• Initiate early enteral nutrition by 72 hours, even in severe cases 2, 5
• Both nasogastric and nasojejunal feeding routes are safe and effective (nasogastric effective in 80% of cases) 1, 2
• Exercise caution with nasogastric feeding in patients with impaired consciousness due to aspiration risk 1
• Avoid total parenteral nutrition, but consider partial parenteral nutrition if enteral route not completely tolerated 2, 3
• If ileus persists >5 days, parenteral nutrition will be required 2

Antibiotic Therapy

Prophylactic antibiotics are not recommended in mild acute pancreatitis. 1, 2, 3

• In severe acute pancreatitis with pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths, though evidence is conflicting 1, 2
• If antibiotic prophylaxis is used, limit duration to maximum 14 days 1, 6
• Intravenous cefuroxime provides reasonable balance between efficacy and cost for prophylaxis 2
• Administer antibiotics when specific infections occur (chest, urine, bile, or cannula-related) 2

Imaging

Mild Cases

• Routine CT scanning is unnecessary unless clinical deterioration occurs 2, 3

Severe Cases

• Obtain dynamic CT scanning within 3-10 days of admission using non-ionic contrast to identify pancreatic necrosis 2, 6, 3
• Patients with persistent symptoms and >30% pancreatic necrosis should undergo image-guided fine needle aspiration 1, 6
• Follow-up CT only if clinical status deteriorates or fails to show continued improvement 2

Management of Gallstone Pancreatitis

Urgent therapeutic ERCP must be performed within 72 hours (ideally within 24 hours if cholangitis present) in patients with suspected or proven gallstone etiology who have severe pancreatitis, cholangitis, jaundice, or dilated common bile duct. 1, 2, 6, 3

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1
• Patients with cholangitis require endoscopic sphincterotomy or duct drainage by stenting 1
• All patients with biliary pancreatitis should undergo definitive gallstone management during the same hospital admission, or within two weeks of discharge 1, 6, 3
• For unfit patients, endoscopic sphincterotomy alone is adequate treatment 1

Management of Pancreatic Necrosis

Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material. 1, 6

• Delay interventions for infected necrosis until at least 4 weeks after disease onset when possible 6
• Implement a step-up approach: start with percutaneous or endoscopic drainage, progress to minimally invasive necrosectomy if no improvement 6
• Consider minimally invasive approaches before open surgical necrosectomy 2

Early Intervention Indications

• Abdominal compartment syndrome unresponsive to conservative management 6
• Acute ongoing bleeding when endovascular approach unsuccessful 6
• Bowel ischemia or acute necrotizing cholecystitis 6

Late Intervention Indications

• Infected necrosis with clinical deterioration 6

Specialist Care and Referral

Every hospital receiving acute admissions should have a single nominated clinical team managing all acute pancreatitis patients. 2, 6

• Refer patients with extensive necrotizing pancreatitis (>30% necrosis) or complications requiring intensive care, interventional radiology, endoscopy, or surgery to specialist units 6, 3
• Multidisciplinary team approach is essential for optimal management 2

Common Pitfalls to Avoid

• Do not use hydroxyethyl starch fluids for resuscitation 3
• Do not routinely administer prophylactic antibiotics in mild pancreatitis 2, 3
• Do not keep patients nil per os unnecessarily—early oral feeding is beneficial when tolerated 3
• Do not rely on specific pharmacological treatments (antiproteases, antisecretory agents, anti-inflammatory agents)—no proven specific drug therapy exists 2, 3
• Do not substitute other pancreatic enzyme products for prescribed formulations without monitoring 7